The PSNet Collection

Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care

November 30, 2021

A 77-year-old man was diagnosed with a rectal mass. After discussing goals of care with an oncologist, he declined surgical intervention and underwent targeted radiotherapy before being lost to follow up. The patient subsequently presented to Emergency Department after a fall at home and was found to have new metastatic lesions in both lungs and numerous enhancing lesions in the brain. Further discussions of the goals of care revealed that the patient desired to focus on comfort and on maintaining independence for as long as possible. The inpatient hospice team discussed the potential role

Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review and meta-meta-analysis.

Sotto KT, Burian BK, Brindle ME. J Am Coll Surg. 2021;Epub Oct 1.

The World Health Organization (WHO) Surgical Safety Checklist has been implemented in healthcare systems around the world. This systematic review and thematic analysis concluded that the surgical safety checklist positively impacts clinical outcomes (surgical outcomes and mortality), process measures, team dynamics, and communication, as well as safety culture. The authors note that the checklist was negatively associated with efficiency and workload; included studies often noted that checklist users felt the checklist slowed down processes within the operating room

Examining the meaning of the language used to communicate the nursing hand-off.

Galatzan BJ, Carrington JM. Res Nurs Health. 2021;44(5):833-843.

During handoffs, nurses are exposed to a variety of interruptions and distractions which may lead to cognitive overload. Using natural language processing, researchers analyzed ten audio-recorded change of shift handoffs to estimate the cognitive load experienced by nurses. Nurses’ use of concise language has the potential to decrease cognitive overload and improve patient outcomes.

Debriefing for Clinical Learning

November 18, 2021

Debriefing is an important strategy for learning about and making improvements in individual, team, and system performance. It is one of the central learning tools in simulation training and is also recommended after significant clinical events.

The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.

Krishnan S, Wheeler KK, Pimentel MP, et al. J Healthc Risk Manag. 2021;Epub Oct 28.

Incident reporting systems are used to detect patient safety concerns and determine potential causes and opportunities for improvements. In the perioperative setting of one hospital, insufficient handoffs were the most common event type in the “coordination of care” category. Use of structured handoffs is recommended to improve communication and patient safety.

Conflict resolution: applying aviation crew resource management in healthcare.

Braverman A. Nurs Manage. 2021;52(9):30-34.

In high-consequence environments, differences of opinion can undermine teamwork and result in operational failure. This article discusses the application of crew resource management (CRM) to the clinical environment. The author outlines steps to translate the aviation CRM experience into the health care domain to improve communication and resolve conflicts in stressful situations.

Quality standards for safe medication in nursing homes: development through a multistep approach including a Delphi consensus study.

Brühwiler LD, Niederhauser A, Fischer S, et al. BMJ Open. 2021;11(10):e054364.

Polypharmacy and potentially inappropriate medications continue to pose health risks in older adults. Using a Delphi approach, experts identified 85 minimal requirements for safe medication prescribing in nursing homes. The five key topics recommend structured, regular review and monitoring, interprofessional collaboration, and involving the resident.

A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia preoperative evaluation associates with increased length of stay and mortality.

Hofer IS, Cheng D, Grogan T. Anesth Analg. 2021;133(3):698-706.

Anesthesia-related adverse events have been associated with increased length of stay, morbidity and mortality. This study investigated the effect of missed documentation of select comorbidities on postoperative length of stay and mortality. Results indicate that missed documentation of one of the comorbid conditions increased risk of length of stay, and mortality was increased with missed atrial fibrillation.

Fidelity and the impact of patient safety huddles on teamwork and safety culture: an evaluation of the Huddle Up for Safer Healthcare (HUSH) project.

Lamming L, Montague J, Crosswaite K, et al. BMC Health Serv Res. 2021;21(1):1038.

Patient safety huddles are used to promote team communication about safety threats. Based on direct observations and a survey of teamwork and safety climate, researchers concluded that patient safety huddles across three National Health Service (NHS) trusts improved teamwork and safety culture, especially for nurses.

Medication reconciliation in the geriatric unit: impact on the maintenance of post-hospitalization prescriptions.

Montaleytang M, Correard F, Spiteri C, et al. Int J Clin Pharm. 2021;43(5):1183-1190.

Previous studies have found that discrepancies between patients’ medication lists and medications they are actually taking are common. This study found that sharing the results of medication reconciliation performed at admission and discharge with patients’ community care providers led to a decrease in medication discrepancies.

Bringing the clinical laboratory into the strategy to advance diagnostic excellence.

Lubin IM, Astles J R, Shahangian S, et al. Diagnosis (Berl). 2021;8(3):281-294.

Diagnostic error reduction continues to be a patient safety focus. This article outlines innovative ways clinical laboratory professionals can support diagnostic excellence, such as improved communication between laboratory professionals, providers and patients.

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery.

Combs CA, Einerson BD, Toner LE. Am J Obstet Gynecol. 2021;225(5):b43-b49.

Maternal and newborn safety is challenged during cesarean delivery due to the complexities of the practice. This guideline recommends specific checklist elements to direct coordination and communication between the two teams engaged in cesarean deliveries. The guideline provides a sample checklist and steps for its implementation.

Massive open online course (MOOC) learning builds capacity and improves competence for patient safety among global learners: a prospective cohort study.

Gleason KT, Commodore-Mensah Y, Wu AW, et al. Nurse Educ Today. 2021;104:104984.

Massive online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in Healthcare MOOC was delivered in 2013 and 2014. At completion of the course, participants reported increased confidence on all six measured domains (teamwork, communication, managing risk, human environment, recognizing and responding, and culture). At 6 months post-completion, the majority agreed the content was useful and positively influenced their clinical practice, demonstrating that MOOCs are an effective interprofessional learning format.

Communication failures contributing to patient injury in anaesthesia malpractice claims.

Douglas RN, Stephens LS, Posner KL, et al. Br J Anaesth. 2021;127(3):470-478.

Effective communication among providers helps ensure patient safety. Through analysis of perioperative malpractice claims using the Anesthesia Closed Claims Project database, researchers found that communication failures contributed to 43% of total claims, with the majority between the anesthesiologist/anesthesia team and the surgeon/surgery team. Methods to improve perioperative communication are discussed.

Implementation of participatory organizational change in long term care to improve safety.

Van Eerd D, D'Elia T, Ferron EM, et al. J Safety Res. 2021;78:9-18.

Working conditions for healthcare workers can affect patient safety. Conducted at four long-term care facilities in Canada, this study found that a participatory organizational change program can have positive impacts on identifying and reducing musculoskeletal disorder hazards for employees, including slips, trips, falls, and ergonomic hazards. Key factors for successful implementation of the change program include frontline staff involvement/engagement, support from management, and training.

Racial disparities in preventable adverse events attributed to poor care coordination reported in a national study of older US adults.

Pinheiro LC, Reshetnyak E, Safford MM, et al. Med Care. 2021;59(10):901-906.

Prior research has found that racial/ethnic minorities may be at higher risk for adverse patient safety outcomes. This study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data collected as part of a national, prospective cohort evaluating stroke mortality. Findings show that Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination (e.g., drug-drug interaction, emergency department visitor, or hospitalization) compared to White participants.

ECHO-Care Transitions Successfully Reduces Patient Readmissions from Skilled Nursing Facilities, Reduces Length of Stay

August 25, 2021

ECHO-Care Transitions (ECHO-CT) intends to ensure continuity of care and alleviate the risk of patient safety issues, notably medication errors, occurring because of hospital transition. With funding from the Agency for Healthcare Research and Quality, Beth Israel Deaconess Medical Center (BIDMC) adapted Project Extension for Community Healthcare Outcomes (ECHO) to connect receiving multidisciplinary skilled nursing facility (SNF) teams with a multidisciplinary team at the discharging hospital. Within one week of discharge, hospital providers discuss each patient’s transitional and medical issues with providers at the SNF using videoconferencing technology. The innovation has successfully reduced patient readmission and SNF length of stay.

Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected

August 25, 2021

A seven-year-old girl with esophageal stenosis underwent upper endoscopy with esophageal dilation under general anesthesia. During the procedure, she was fully monitored with a continuous arterial oxygen saturation probe, heart rate monitors, two-lead electrocardiography, continuous capnography, and non-invasive arterial blood pressure measurements.

New Horizons in Patient Safety. Safe Communication: Evidence-based Core Competencies with Case Studies from Nursing.

Hannawa AF, Wendt AL, Day LJ. Berlin, GER: Walter De Gruyter; 2018. ISBN: 9783110453041.

Poor communication is often associated with unsafe medical care. This companion volume uses the case study format to illustrate nursing communication practices to be targeted by education strategies to improve patient safety.

Effects of a brief team training program on surgical teams' nontechnical skills: an interrupted time-series study.

Gillespie BM, Harbeck EL, Kang E, et al. J Patient Saf. 2021;17(5):e448-e454.

Nontechnical skills such as teamwork and communication can influence surgical performance. This Australian hospital implemented a team training program for surgical teams focused on improving individual and shared situational awareness which led to improvements in nontechnical skills.

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